Fig. 9.Fig. 9.—Interior of one of the Wagons of No. 2 Hospital Train
Hospital Ships.—These were numerous and some especially well arranged. Fig. 10 is of the 'Simla,' a P. & O. vessel which was admirably adapted to the requirements of a hospital ship. On her main deck some 250 patients were accommodated in a series of wards all on the same level, which much lightened the difficulties of service usually experienced. During the present campaign the abundance oftransport vessels rendered the transhipment of patients to England a matter of comparative ease, and good vessels were always available. Considering the constant transhipment of invalids from India and our other colonial possessions, it would seem advisable that, in place of having to hurriedly improvise hospital ships, the Government should possess two or three hospital ships of the 'Simla' type. It is true this would deprive our naval transport officers of a duty which in this war was performed with extraordinary celerity and success; thus the 'Simla' was fitted in seven days, and sailed with a cargo of invalids ten days after her arrival at Durban; but on the other hand it would ensure that really suitable vessels were always provided.
Fig. 10.Fig. 10.—P. & O. Hospital Ship 'Simla' in Durban Harbour
To give some idea of the amount of work contingent on the transport of wounded men from an army of some 15,000, fighting its way against continued opposition, I will quote the approximate number of men moved during Lord Methuen's advance from Orange River to Magersfontein. (The numberof men actually present at each battle is shown in Table I., p. 12.)
Belmont, the first battle, was fought on November 23.
November 24.—No. 2 hospital train removed 152 cases to the Stationary Field hospitals at Orange River, then returned and loaded up with 130 more. Some of the most severe cases in the latter were detrained at Orange River, and the remainder were taken direct to Wynberg (591½ miles).
The division marched, and the battle of Graspan was fought during the day.
November 26.—A train of specially constructed trucks brought 90 of the less severe cases, including 20 Boers, to Orange River.
November 27.—The division marched, and in the morning No. 3 hospital train removed 80 severe cases from the Field hospitals direct to Wynberg.
November 28.—Battle of Modder River.
November 29.—339 patients, including a few sick, and some wounded Boers, were sent down to Orange River in open trucks with impromptu shelters made with rifles and blankets.
Later, 97 severe cases were sent down in ordinary carriages, of which some had doors sawn out to admit lying-down patients.
December 10.—The division marched, and on the next day the battle of Magersfontein was fought.
December 11.—Nos. 2 and 3 trains were loaded up during the night and early morning of the 12th, in part from the Field hospitals, in part directly from the Ambulance wagons. During the day of the 12th, No. 3 train made three journeys to Orange River, and No. 2 was sent direct to Wynberg.
In all some 800 patients needed transport; they were picked up by 10 ambulance wagons and 5 buck wagons for slighter cases and the two bearer companies sent out from Modder River. On the 12th Lord Methuen sent out a number of bearers with stretchers, and at 12 noon all the wounded were collected, but many had lain out through the night. The bearers had to retire under a shell fire kept up by the Boers as long as our army was within range of their position.
Four Field hospitals were present, but only that of the IX. Brigade at Modder River was so situated as to be of general use. This hospital, under the command of Major Harris, R.A.M.C., did an immense amount of work most expeditiously and with great success.
The nature of the advance on Kimberley necessitated the evacuation of the Field hospitals with extreme promptitude, as the troops were in constant action, and the arrangements for this were carried out with great success by Colonel Townsend, the P.M.O. of the First Division.
The amount of fighting far exceeded anything that had been expected, and the Stationary hospitals on the lines of communication at Orange River and De Aar were unable to cope with the number of severe cases thrown on their hands, with the constant possibility of new arrivals. Hence a number of severe cases had to be sent direct to Wynberg.
This experience strongly illustrated the necessity of possessing Stationary hospitals of greater mobility and a higher degree of equipment than the service at present possesses. In these a large number of severe cases could have been retained, and only the slighter ones exposed to the fatigue and general disadvantage of transport. In South Africa very special difficulties existed in the length of the line of communication, the single line of rails, and the absence of any source of supply within 500 to 600 miles; but in any other country mobile Stationary hospitals, although more easily equipped, would be equally valuable.
The difficulties of transport experienced in the advance of the Kimberley Relief Force were many times multiplied in that upon Bloemfontein, since the whole of the severely wounded men had to be sent back thirty to forty miles to the railway. The ambulance accommodation on the occasion of this march, although, if untouched, proportionately smaller than that possessed by Lord Methuen, was reduced to one-fifth to meet the exigencies of warfare. Beyond this the equipment transport of the Field hospitals was reduced from four ox-wagons to two, and the Scotch cart was cut off, only two ox-wagons and the two water-carts being allowed. This greatly hampered the Field hospitals on the march, and when they arrived atBloemfontein and had to undertake the work of Stationary hospitals, their efficiency was seriously impaired. Again, on the advance from Bloemfontein to Kroonstadt many of the Field hospitals were unable to accompany their respective divisions, not alone on account of the number of patients remaining in them, but also because the mule transport had been otherwise employed for military purposes.
The transport of the ambulances and hospitals stands in a very special position. As far as my experience went, neither ambulances nor hospitals were ever taken or retained by the Boers, and consequently the transport animals originally devoted to this purpose should have been held sacred to it.
Hospitals.—Accommodation for the wounded was provided under canvas in the Field hospitals, also in the large General hospitals. Beyond this iron huts were erected in many of the Base and Station hospitals. At Capetown, Maritzburg, and Ladysmith barrack huts were modified and equipped as hospitals, and in towns such as Bloemfontein, Kimberley, and Johannesburg large civil hospitals were at our disposal. Beyond these sources of accommodation, churches, schools, public institutions, and private houses were made use of in the smaller towns.
As to the broad question of canvasv.buildings, experience amply showed that in a climate such as is possessed by South Africa, canvas affords the greater advantages. The hospitals are more mobile, more readily extended, and the more healthy. Except under unusual conditions of rain and dust, the patients did excellently in the tents.
Rain and dust were occasionally most troublesome, especially when combined with wind. I once saw a whole hospital, fortunately unoccupied, levelled to the ground in the course of some twenty minutes. Under such circumstances iron huts present advantages, and were on many occasions utilised with much success. They are readily erected, and it would have been a considerable improvement if a number of them had been ready for use at the earliest part of the campaign. Except in the matter of weight, they possess in a considerable degree the advantage of mobility possessed by canvas, and in addition they offer much moreprotection from the weather. On the other hand, they are more liable to become unhealthy from prolonged use.
Churches and public institutions were mainly troublesome from the necessity of having to improvise sanitary arrangements, and sometimes the disadvantage of the collection of a large number of men in one chamber could not be avoided. None the less I cannot look back without admiration on the temporary hospitals established in the Raadzaal at Bloemfontein, and the Irish hospital in the Palace of Justice in Pretoria.
The State schools in the smaller towns of the Orange River Colony also afforded excellent accommodation as small temporary hospitals.
Private houses, possessing the disadvantages of ill-adapted construction and the necessity of a considerably increased staff to work them, were on the whole little used as hospitals. The scattered farmhouses occasionally afforded shelter to very severely wounded men. In most of the country I traversed, however, the farms were so wide apart as to be of little use in this respect; and again, under the special circumstances, patients left in them might have to be abandoned to the enemy.
The chief interest during the campaign centred in the working of the Field and General hospitals.
Two types of Field hospital were employed, one the Home, the other the Indian. The latter differs from the Home in that in it the bearer company is attached and consists of Indian natives, and that the hospital is separable into four sections in place of two only.
The amalgamation of the Field hospital and bearer company into one unit is much to be desired in the Home service, both for economy of working and the more equal distribution of duties to the medical officers engaged. Again the divisibility of the hospital into four sections is also an advantage. It allows of the advance or the leaving of sections, in the case of either small expeditions or the presence of a number of severely wounded men unfit to travel. As far as I could judge, it necessitates very small addition to the present equipment, and is in every way desirable.
As to the working of the Field hospitals in the presentcampaign, it was universally acknowledged to possess a very high degree of excellence. The equipment, with small exceptions, proved equal to the demands made upon it. The mobility of the camps was proved again and again, and the rules governing their administration evidenced by their effectiveness the care and experience which have been bestowed on the organisation of the hospitals.
It is difficult for any one who has not had an opportunity of observing the actual amount of work performed in the Field hospitals either to appreciate the storm and stress following an important engagement when the wounded men are first brought in, or the demands that are made on the powers of the medical officers in charge. To a civilian the first feeling is one of impotence, followed by an attempt to see no further than the case under immediate observation, and to nurture the conviction that the work is to be got through if it is only stuck to. I gathered that this first impression was absent in the minds of the officers in charge of the Field hospitals, as work commenced at once, and was carried on without intermission during the persistence of daylight, in the winter often by the aid of lanterns, and eventually the huge task was accomplished. In early days at Orange River work commenced at 4a.m., and was steadily continued until 6p.m.or later, and this state of things persisted sometimes for many days together.
The officers of the Field hospitals, the bearer companies, and those doing regimental duty carried out their duties with a calmness and efficiency which not only impressed observers like myself, but also excited the admiration of our German colleagues sent by their government to observe the working of the British system.
I saw on several occasions the German and Dutch ambulances, and was much struck by the excellence of their equipment. In some details there was much to be learned from them, especially in the matter of appliances, dressings, and instruments. The Dutch ambulance I saw at Brandfort had a complete installation of acetylene gas, which was carried, gasometer and all, in one Scotch cart. They were, however, really designed to fill the combined position of ourField, Stationary, and General hospitals, and when it became necessary for them to move about frequently, the inferior mobility they possessed in comparison with our own Field hospitals was at once demonstrated.
The large General hospitals of 500 beds were a great feature in the campaign. Although designed and organised some time since, the present was the first occasion on which they have come into general use, and they may be said to have actually been on trial. The organisation of these hospitals proved itself excellent, and in the case of the best of them left little to be desired.
In some cases the accommodation was temporarily strained enormously, and the number of patients was extended beyond more than three times the regulation limit. The additional patients were then accommodated in marquees and bell tents, according to the nature of their diseases. Under these circumstances the working of the hospitals was difficult, and the officers both of the R.A.M.C. and the civilian surgeons were placed at a great disadvantage.
My space does not allow me to give any description of the general arrangement of these hospitals, but I would suggest that a certain number of them should be so modified as to increase their mobility and allow of their being more readily utilised as Stationary hospitals.
During the whole campaign it seemed to me that the Stationary hospitals (that is to say, the hospitals necessary to receive patients when the Field hospitals were rapidly evacuated), were those in which some increased uniformity of organisation was most needed.
It scarcely needs to be pointed out that this is the most difficult link of the whole hospital chain to be uniformly well organised and equipped. It is needed at short notice, and often for a short period, and it is difficult to maintain a regular staff of officers ready for any emergency without keeping a certain number of men idle.
The conversion of Field hospitals to Stationary purposes is undesirable, as the troops move with only a regulation number of the former, which under ordinary circumstances is the minimum that may be necessary.
Stationary hospitals as individual units are undesirable for the reasons above given.
Fig. 11.Fig. 11.—Type of a General Hospital (No. VIII. Bloemfontein) extended by use of bell tents in the distance. (Photo by Mr. C. S. Wallace)
The difficulty might be met by increasing the mobility of a certain number of the General hospitals, by making them divisible into five sections, each of which should be able to move independently, and to the last of which should be attached the heavy part of the equipment, such as the iron huts for operating and X-ray rooms, kitchens, store sheds, &c. The tents might also be lightened by the substitution of the tortoise tent for the service marquee. The tortoise tent is lighter (360 as against 500 lbs.), easily pitched and moved, and holds at least two more patients with ease. The capabilities of this tent were amply proven during its use by the Portland, Irish, and other civil hospitals attached to the army. It withstood wind and weather, the former better than the service marquee. Figs. 11 and 12 show the appearance of camps composed of the two varieties. I must admit a warm preference for the appearance of the service pattern,but I think it is indubitable that the other is the more useful.
Given the possibility of division of a General hospital in this manner, single sections could readily be sent up the lines of communication to serve as Stationary hospitals at various points behind the advance of the troops, and on the cessation of active need, the sections could be reunited at any point to form an advanced Base hospital. The sections could be kept in touch throughout by visits from the officer of the lines of communication. This would appear a ready means of providing well-organised Stationary hospitals at short notice, and would save the disadvantage of a definitely separate series.
Fig. 12.Fig. 12.—Type of Tortoise Tent Hospital. Portland Hospital, Bloemfontein. (Photo by Mr. C. S. Wallace)
Such hospitals might have been used on many occasions when the transport of an entire General hospital was an impossibility. The service, moreover, has some experience in this direction, since at one time No. 3 General Hospital was divided into two definite sections.
Bearing in mind the extreme readiness and promptitude with which the officers during the present campaign extended the accommodation of either Field or General hospitals, one ofsuch sections as are proposed might readily be made far more capacious than its regulation number would suggest.
My duties being entirely in connection with the service hospitals, I did not become intimately acquainted with any of the volunteer hospitals which did such excellent service, except the Portland, to the staff of which I was indebted for much hospitality and kindness. This hospital was practically of about the capacity proposed for the above-mentioned sections, and the report of its work will no doubt furnish many points of detail as to equipment, &c., which may be useful.
The general results of the surgical work done during the campaign were excellent, and taken as a whole the occurrence of any severe form of septic disease was unusual.
Pure septicæmia, especially in connection with abdominal injuries, severe head injuries and secondary to acute traumatic osteo-myelitis, was the form most commonly seen. Pyæmia with secondary deposits was uncommon, and often of a somewhat subacute form; thus I saw several patients recover after secondary abscesses had been opened, or the primary focus of infection removed. The only really acute case of joint pyæmia I heard of, developed in connection with a blistered toe followed by cellulitis of the foot.
Cutaneous erysipelas I never happened to see, and really acute phlegmonous inflammation was rare.
I may mention the occurrence of acute traumatic gangrene in two cases. This developed in each instance with gunshot fracture of the femur; in one amputation was performed, and the process extended upwards on to the abdomen. The cases occurred with the army in the field in the neighbourhood of Thaba-nchu and not in a stationary hospital.
Acute traumatic tetanus occurred only in one instance to my knowledge. In this case the primary injury was a shell wound of the thigh, and the patient developed the disease and died within ten days.
To the civil surgeon the performance of operations, and the dressing of severe wounds at the front, proved on occasions a somewhat trying ordeal.
When operations were necessary in the field, during the daytime, it was often possible to perform them in the openair, provided tolerable protection could be obtained from the sun. A number of cases were so operated upon during the march of the Highland Brigade from Wynberg to Heilbron, and gave excellent results, the patients deriving considerable benefit from the early cleansing and closure of the wounds.
Fig. 13.Fig. 13.—Tortoise Hospital Tent. Portland Hospital. (Photo by Mr. C. S. Wallace)
In camp, in the Field, or Stationary hospitals, the difficulties were often much greater. The operations were necessarily performed under shelter for reasons of privacy. In the tents the draught carrying the dust from the camp was one of the commonest troubles. The exclusion of dust was impossible, and it not only found its way into open wounds, but permeated bandages with ease. Often when a bandage was removed, an even layer of dust moistened by perspiration covered the whole area included with a coating of mud. Again, in dust storms a similar layer of mud sometimes covered the whole of the exposed parts of the bodies of patients lying on the ground in the tents.
It is of some interest to remark with regard to this dust, that Dr. L. L. Jenner lately kindly examined a specimen collected at Modder River after the camp had been more than two months established, and discovered no pathogenic organisms in it. As a period of seven months had elapsed since this dust was collected, the fact is of no practical import, beyond showing that, if such organisms had existed, at any rate they were not of a resistent nature.
Insects, particularly common house-flies, were an intolerable pest at times. In a fresh camp they were sometimes not abundant, but after two or three days they multiplied enormously. Not only hospital tents, but living and mess tents, swarmed with them, the canvas appearing positively black at night. Even when dressing a wound, without unceasing passage of the hand across the part, it was impossible to keep them from settling, and during operations the nuisance was much greater.
Storms of rain were occasionally as troublesome as, though perhaps less harmful than, those of dust. On one occasion a whole Field hospital was flooded only a few hours after a number of important operations had been performed, and the patients were practically washed out of the tents. It was somewhat remarkable that none of the men suffered any serious ill as a result.
At times the temperature was sufficiently high to make either dressing or operating a most exhausting process to the surgeon. The heat of the day was not on the whole so disadvantageous from the point of view of the operator, as the cold of the nights during the winter in Orange River Colony. On one or two occasions serious operations had to be left undone, as it was only possible to consider them in camp, where, as we arrived at night only, the temperature was too low to justify the necessary exposure.
Water for use at operations was often a great difficulty. Even at Orange River, where, though muddy, the water was wholesome, it was impossible to get water suitable for operations unless it had previously gone through the complicated processes of precipitation by alum, boiling, and filtration. At Orange River a small room in the house of one of the railwayservants was obtained and fitted as a rough operating room by the Royal Engineers. The necessary utensils were provided by Colonel Young, Commissioner of the Red Cross Societies. Here a stock of prepared water was kept for emergencies.
The remaining difficulties mainly consisted in those we are familiar with in civil practice, such as the securing of suitable assistance in the handling of instruments and dressing, when the rush of work was very great.
At the Base hospitals accommodation for operating in properly equipped rooms obviated many of the difficulties above referred to.
In concluding this introduction I should sum up in a few words my experience of the general working of the hospital system during my stay in South Africa.
The excellence of the Field hospitals for their purpose has been already alluded to, and, as far as I could ascertain, won the confidence and approval of patients, military commanders, and civilians such as myself.
The Stationary hospitals (by which I intend to indicate those receiving the patients directly from the Field hospitals before the establishment of advanced Base hospitals), as already indicated, were not in my opinion so perfectly conceived or organised. The requirements of these are, however, far greater than those of the Field hospitals, and they of all others are dependent on the possession of facilities for rapid transport. In South Africa the difficulties of supplying them were enormous, and no doubt the conditions of the campaign in this, as so many other particulars, were novel and unusual. None the less the experience gained will no doubt be utilised in the future. With regard to the extravagant criticisms levelled at the Field hospitals serving as Stationary hospitals at the time of the early period of the occupation of Bloemfontein, it may be pointed out that the only proper ground for comparison was not between the patients at Bloemfontein and those in hospital at the base, but between the men in hospital and those in the field at that time, since the conditions were equally adverse to both. Besides, it must not be forgotten that a large proportion of the patients, at that time, were really comfortably housed inthe Raadzaal and other buildings, the preparation of which entailed a very great amount of both labour and resource.
The difficulties experienced at that time will, it is hoped, go far towards securing greater facilities and rights of transport to the Royal Army Medical Corps in the future. As a civilian, one cannot but recognise that the conditions of modern warfare are much altered from those of the past. Prisoners are well cared for and kindly treated, the sick and wounded are respected by both sides, and except in the actual horrors of fighting the condition of the soldier is a happier one. Under these circumstances the limitation of the transport facilities of a department so closely concerned with the well-being of all, and which has been organised on a most moderate scale, must soon become a tradition of the past in civilised armies.
As to the efficiency of the organisation of the General hospitals, either at the advanced or actual base, I have already testified. Naturally the working of these hospitals varied with the personal equation of the officer in charge of them, but as a whole the service has every reason to be proud of their success. As far as surgical results are concerned, and with these I had special acquaintance, the success of the hospitals was amply demonstrated.
Adverse criticism was not however wanting, and often expressed in the strongest terms by persons totally unacquainted with hospital methods, and apparently unconscious that such excellence as is exhibited in a London hospital is the result of continuous work and development for some centuries, and that such institutions are worked by committees and staffs of permanent constitution.
The proportion of female nurses employed in these hospitals underwent steady increase from the commencement of the campaign, and the immense value of the nursing reserve was fully proved. There is no doubt that in Base hospitals the actual nursing should always be entrusted to women.
The demands of the campaign necessitated the employment of a large number of civil surgeons in the various hospitals. These gentlemen accommodated themselves withtrue British aptitude to the conditions under which they were placed, and in all positions their sterling work contributed in no small degree to the success that was attained.
One class of hospital still remains for mention. I refer to the improvised hospitals prepared in the Boer towns prior to the British occupation. They were met with in all the smaller towns, and also in the larger ones such as Johannesburg and Pretoria.
The Burke hospital in Pretoria, started by a private citizen and his daughter, and the Victoria hospital in Johannesburg, presided over by Dr. and Mrs. Murray, were two of the largest, but each and all deserve due recognition.
I am sure that many of our wounded officers and men who were cared for in these hospitals while prisoners in the hands of the Boers, will never lose their sense of gratitude to those inhabitants who spared no effort to render their position as happy as possible under the circumstances; and the existence of these hospitals was no small boon to the service when called upon to take charge of the sick and wounded therein contained.
I cannot close this chapter without recognition of the immensity of the task which has fallen on the Royal Army Medical Corps in the treatment of the sick and wounded during the course of the campaign and full appreciation of the manner in which that task has been met. The strain thrown upon this department of the service, originally organised for the needs of an army less than half the magnitude of that eventually taking the field, was incalculably great, and the medical profession may well be proud of the efforts made by its military representatives to do the best possible work under the circumstances.
FOOTNOTES:[1]3,328 men of the IX. Brigade present are not included, as they never came into action.[2]The high mortality was due to deaths amongst the officers of the Naval Brigade.[3]To obtain this total the numbers of killed, wounded, and missing, after the three earlier battles, have been massed, and added to the total number of men known to have taken part in the battle of Magersfontein. The inaccuracy dependent on the fact that some of the men reported as wounded or missing in the earlier battles had already returned to their regiments, and are included in the total of 11,447, must be disregarded.[4]Numbers quoted from Fischer,Handbuch der Kriegschirurgie, vol. i. p. 22, 1882.
[1]3,328 men of the IX. Brigade present are not included, as they never came into action.
[1]3,328 men of the IX. Brigade present are not included, as they never came into action.
[2]The high mortality was due to deaths amongst the officers of the Naval Brigade.
[2]The high mortality was due to deaths amongst the officers of the Naval Brigade.
[3]To obtain this total the numbers of killed, wounded, and missing, after the three earlier battles, have been massed, and added to the total number of men known to have taken part in the battle of Magersfontein. The inaccuracy dependent on the fact that some of the men reported as wounded or missing in the earlier battles had already returned to their regiments, and are included in the total of 11,447, must be disregarded.
[3]To obtain this total the numbers of killed, wounded, and missing, after the three earlier battles, have been massed, and added to the total number of men known to have taken part in the battle of Magersfontein. The inaccuracy dependent on the fact that some of the men reported as wounded or missing in the earlier battles had already returned to their regiments, and are included in the total of 11,447, must be disregarded.
[4]Numbers quoted from Fischer,Handbuch der Kriegschirurgie, vol. i. p. 22, 1882.
[4]Numbers quoted from Fischer,Handbuch der Kriegschirurgie, vol. i. p. 22, 1882.
Before proceeding to the actual description of the wounds inflicted by modern military rifles, it is necessary to prefix a few remarks on the mechanism and mode of production of these injuries.
Recent tendency in the construction of military rifles has been in the direction of reduction of bore, and a corresponding one in the calibre of the bullet, the resulting loss of weight in the latter as an element in striking power being compensated for by the attainment of an augmentation of velocity in the flight of the projectile, and a comparatively flat trajectory.
Changes in this direction have endowed the weapons with increase both in range and accuracy of fire; while the greater rapidity with which magazine rifles can be discharged and, in consequence of reduction in weight, the greater number of cartridges which can be carried by each man, also form important factors in the possible deadliness of warfare at the present day. None the less the experience of the present campaign has scarcely justified the early prognostications expressed as to a great increase in the number and severity of wounds amongst the combatants.[5]This comparative immunity is to be explained mainly on two grounds. The increased distance which for the most part separated the two bodies of men, a feature no doubt accentuated by the mode of warfare adopted by the Boer, and his strong sense of the folly of close combat on equal terms, tended to efface one of the chief characters, velocity of flight, on the part of the projectile. The want ofeffectiveness of the small-calibre bullet as an instrument of serious mischief also kept down the mortality.
Since the year 1889 the calibre of the bullet in our own army has been reduced from that of the Martini-Henry (.450 in.) to one of .309 in. in the Lee-Metford, and a consequent reduction in weight from 480 to 215 grains. To allow of the satisfactory assumption of the more complicated rifling by the more rapidly projected bullet, the lead core has been ensheathed in a mantle of denser metal. The bullet itself is of an original calibre (.309 in.) somewhat exceeding the bore of the rifle barrel (.303 in.), in which way a species of 'choke' is obtained and deep rifling of the surface ensured. Beyond this the comparative transverse and longitudinal measurements and shape have been altered in order to maintain weight, preserve a proper balance during flight, and increase the power of penetration. These alterations with slight differences in detail embody the general principles that underlie the construction of each of the weapons adopted by European nations. It will be well here to consider the influence of each alteration from the point of view of the surgeon.
Calibre.—The effect of the diminution of calibre is (a) to reduce the area of impact of the bullet on the part impinged upon, and hence to lower the degree of resistance offered by the tissues; this to a certain extent tends to neutralise the augmented striking force resulting from the increased velocity of flight. (b) To limit considerably the destructive powers of the bullet, as a smaller area of tissue is exposed to its action. (c) To allow of the production of very 'neat' injuries and the frequent escape of important structures, also the production of remarkably prolonged subcutaneous tracks in positions where such would be regarded as scarcely possible, and in point of fact were impossible with the older and larger projectiles.
Length.—The comparative increase in length of the bullet is, from the surgical point of view, only of material importance in increasing the weight and therefore the striking power, and in so far as it is a mechanical necessity for the flight of the projectile on an axis parallel to its long diameter,and so tends to ensure impact on the body by the tip of the bullet. This latter is, however, surgically favourable as ensuring a smaller wound.
Weight.—The decrease in weight must be regarded on the whole as altogether to the advantage of the wounded individual, since it cannot be considered to be entirely compensated for by the resulting increased velocity of flight, unless the range of fire is moderately close.
Shape.—The ogival tip and general wedge-like outline, while decreasing the aerial resistance to and increasing the power of penetration possessed by the bullet, at the same time allow the escape of some structures by displacement, while others are saved from complete destruction by undergoing perforation. Beyond this the sharper the tip, the smaller is the area of the body primarily impinged upon, the less the resistance offered to perforation, and to some degree the less the destruction of surrounding tissues.
Increased velocity of flight.—This multiplies the striking force, and compensates in part for decrease in volume and weight of the bullet. It is customary to speak of the velocity as 'initial' and 'remaining.' Initial velocity is the term employed to express the velocity at the time of the escape of the bullet from the barrel; this is also designated as 'muzzle velocity.' 'Remaining velocity' expresses that obtaining during any subsequent portion of the flight of the projectile.
The greatest initial velocity is obtained with the use of bullets of the smallest calibre, but this is not of the practical importance which might be assumed, since the remaining velocity of flight of such projectiles falls more rapidly than that of those of slightly greater mass. Thus, although there may be a difference of a hundred metres per second in initial velocity between two rifles of calibres varying from 6.5 to 8 millimetres (.303-.314 in.), at the end of 1,000 metres the discrepancy is greatly reduced, while at 2,000 metres it hardly exists. Under such circumstances the projectile of greater weight and volume, as possessing the greater striking force, is considerably the more formidable of the two. This is the more important if it be allowed, as I believe to be the case, that velocityper seis of no practical import in thecase of wounds of the soft parts of the body, which after all form the preponderating number of all gunshot injuries. The effect of the higher degrees of velocity differs, however, with the amount of resistance met with on the part of the body; hence its serious import is well exemplified when parts of the osseous skeleton are implicated, although even here considerable variations exist, dependent upon the structure of that part of the bone actually involved. The most obvious ill effect of injuries from bullets travelling at high rates is seen in the case of the various parts of the nervous system, and here it is undeniable. High velocity and striking force are also responsible for the prolonged course sometimes taken by bullets through the body.
The actual degree of velocity, as judged by the range of fire at which an injury is received and the resulting injury, is very hard to estimate on account of the many and varying factors which enter into its determination. The mere recital of some of these will suffice to make this evident.
1. Quality of the individual cartridge employed, as to loading, the materials employed, and their condition.
2. The condition of the rifle as to cleanliness, heating, and the state of the grooves of the barrel.
3. The angle of impact of the bullet with the part injured.
4. Resistance dependent on the weight of the whole body of the man struck, or of an isolated limb.
5. Special peculiarities of build in the individual struck, such as thickness and density of the integument and fasciæ, strength and thickness of the bones, &c.
6. State of tension of the muscles, fasciæ, and ligaments at the moment of impact, and fixity or otherwise of the part of the body struck.
7. The degree of wind, temperature, and hygroscopic conditions of the atmosphere.
These form some of the more important points which have to be taken into consideration, in addition to a mere calculation of the actual distance from which a wound has been received from a particular rifle, and taken with the unsatisfactory nature of the evidence as to the latter, which is usually alone obtainable, it is clear that definite assumptions are scarcelypossible. In a great number of cases I came to the conclusion that the only indisputable evidence of low velocity was the lodgment of an undeformed bullet. There is little doubt, moreover, that the general tendency of wounded men was to minimise the range of fire at which they were struck, and again that in the majority of cases in this campaign it was quite impossible to determine whence any particular bullet had come, since the enemy was seldom arranged in one line, but rather in several. Again, smokeless powder was generally employed. Beyond this, in some cases where there was no doubt of the short distance from which the bullet was fired, the wounds were due to 'ricochet' of portions of broken-up bullets. The following instance well illustrates this. A sentry fired five times at two men within a distance of six paces, knocking both down. One man received a severe direct fracture of the ilium, the bullet entering between the anterior superior and inferior iliac spines and emerging at the upper part of the buttock. The entry and exit apertures were large but hardly 'explosive,' as a subcutaneous track four to five inches long separated them. Besides this both men had other lesser injuries; thus in the second two perforating wounds of the arm existed. The latter were not unlike type Lee-Metford wounds, and were regarded as such until a few days afterwards when a hard body was felt in the distal portion of one track and removed. This proved to be a part of the leaden core only, and the similar wound had no doubt been produced by a like fragment, the bullet having broken up on striking the stony ground.
Trajectory.—The comparative flatness of this depends on the construction of the rifle and the propulsive force employed, and varies as does velocity with the nature, excellence, and amount of the explosive, the correctness of the principles upon which the bullet is devised, and the mechanical perfection of its manufacture. Its importance naturally consists in the manner in which it affects the possibility of covering objects on a wide area of ground and thus creating a broad 'dangerous zone.' A bullet fired on level ground from any one of three of the rifles referred to later (Lee-Metford, Mauser, Krag-Jörgensen), sighted to 500yards and fired from the shoulder in the standing position, will cover some part of an erect man of average height during the whole extent of its flight. A body of men within that distance is therefore in a position of extreme peril in the face of a good shooting enemy.
The importance of a flat trajectory is progressively lost, however, with any rifle, as the weapon is gradually sighted to greater distances. Thus when sighted to 2,000 yards the bullet from the Lee-Metford rifle rises 174 feet, and a whole army might comfortably be situated over a considerable area within that distance. The importance of flatness of trajectory is also influenced by the nature of the ground occupied by the combatants. Thus when the area to be covered consists in ground first rising then falling from the rifleman, the trajectory will become more or less parallel to the surface crossed, and the 'dangerous zone' will be correspondingly increased in extent. On the other hand, when the ground slopes away from the rifleman the rise of the projectile is exaggerated, and reaches its most limited capacity of covering an intervening space when the flight crosses a hollow.
Revolution of the bullet.—It only remains in this place to say a few words concerning the revolution imparted to the bullet by the rifling of the barrel. This ensures the flight of the projectile on a line parallel to its long axis, and notably increases its power of penetration.
Both these properties of the flight are to the advantage of the wounded, since, as already mentioned, the more exactly the impact corresponds to a right angle with the skin, the more limited will be the area of contusion, even if it be of the most severe character, while to the twist of the bullet must be ascribed a not inconsiderable part in the explanation of the ready and neat perforations of narrow structures which are frequently produced.
It has been pointed out that the Lee-Metford bullet turns on its own axis once in a distance of ten inches, while the Mauser revolves once in a distance of eight and eleven-sixteenths inches; hence not more than at most two revolutions are made in tracks crossing the trunk, and not more than half a full revolution in the perforation of a limb. None theless, no one can deny the influence of the one half turn of supination in entering a perforating tool of any description, both as preventing splintering, and in preserving the surrounding parts from damage.
Beyond this, the spiral turn of the bullet, by diverting a part of the transmitted vibrations into a second direction, must, in the case of wounds of the body, help to throw off contiguous structures, and while those that are in actual contact are more severely contused, the surrounding ones suffer somewhat less direct injury. It must be borne in mind, also, that rapidity of revolution does not fallpari passuwith that of velocity of flight, but that the former undergoes a comparatively slighter diminution until the bullet is actually spent. Hence, the influence of revolution is felt, however low the velocity may be, provided sufficient striking force is retained to enter the body. A word must be added here as to the surface of a discharged bullet; this, in taking the rifling of the barrel, becomes permanently grooved. The depth of the groove differs with the variety of rifle. In the Lee-Metford the grooves are deep (.009), in the Mauser slightly less so (.007), but the surface of both bullets is comparatively roughened when revolving in the body, and this circumstance, since the projectile exactly fits its track, may influence the degree of the surface destruction of tissue, and somewhat aid in the clean perforation of bone, since a little bone dust is always found at the entrance aperture of a canal in cancellous bone.
During the campaign many varieties of rifle projecting bullets of widely differing calibre were employed by the Boers, many of whom as sportsmen preferred the rifle to which they were accustomed to a regulation weapon, and an illustration of a large variety of bullets from cartridges which I collected from arsenals and camps is given below (p. 96). The great majority of the men, however, were armed with small-calibre weapons of some sort, and as the wounds produced by these are of chief interest at the present day, I shall say little of any others, beyond an occasional reference to Martini-Henry rifle wounds which may be considered to represent approximately those made by large leaden sporting bullets.